Evidence and gap map report: Social and Behavior Change Communication (SBCC) interventions for strengthening HIV prevention and research among adolescent girls and young women (AGYW) in low‐ and middle‐income countries (LMICs)

Abstract Background Adolescent girls and young women (AGYW), aged 15–24 years, are disproportionately affected by HIV and other sexual and reproductive health (SRH) risks due to varying social, cultural, and economic factors that affect their choices and shape their knowledge, understanding, and practices with regard to their health. Socio‐Behavioral Change Communication (SBCC) interventions targeted at strengthening the capabilities of individuals and their networks have supported the demand and uptake of prevention services and participation in biomedical research. However, despite growing global recognition of the domain, high‐quality evidence on the effectiveness of SBCC remains scattered. This evidence and gap map (EGM) report characterizes the evidence base on SBCC interventions for strengthening HIV Prevention and Research among AGYW in low‐ and middle‐income countries (LMICs), identifying evidence gaps and outlining the scope of future research and program design. Objectives The objectives of the proposed EGM are to: (a) identify and map existing EGMs in the use of diverse SBCC strategies to strengthen the adoption of HIV prevention measures and participation in research among AGYW in LMICs and (b) identify areas where more interventions and evidence are needed to inform the design of future SBCC strategies and programs for AGYW engagement in HIV prevention and research. Methods This EGM is based on a comprehensive search of systematic reviews and impact evaluations corresponding to a range of interventions and outcomes—aimed at engaging AGYW in HIV prevention and research ‐ that were published in LMICs from January 2000 to April 2021. Based on guidance for producing a Campbell Collaboration EGM, the intervention and outcome framework was designed in consultation with a group of experts. These interventions were categorized across four broad intervention themes: mass‐media, community‐based, interpersonal, and Information Communication and Technology (ICT)/Digital Media‐based interventions. They were further sub‐categorized into 15 intervention categories. Included studies looked at 23 unique behavioral and health outcomes such as knowledge attitude and skills, relationship dynamics, household dynamics, health care services, and health outcomes and research engagement. The EGM is presented as a matrix in which the rows are intervention categories/sub‐categories, and the columns are outcome domains/subdomains. Each cell is mapped to an intervention targeted at outcomes. Additional filters like region, country, study design, age group, funding agency, influencers, population group, publication status, study confidence, setting, and year of publication have been added. Selection Criteria To be eligible, studies must have tested the effectiveness of SBCC interventions at engaging AGYW in LMICs in HIV prevention and research. The study sample must have consisted of AGYW between the ages of 15–24, as defined by UNAIDS. Both experimental (random assignment) and quasi‐experimental studies that included a comparison group were eligible. Relevant outcomes included those at the individual, influencer, and institutional levels, along with those targeting research engagement and prevention‐related outcomes. Results This EGM comprises 415 impact evaluations and 43 systematic reviews. Interventions like peer‐led interactions, counseling, and community dialogues were the most dominant intervention sub‐types. Despite increased digital penetration use of media and technology‐driven interventions are relatively less studied. Most of the interventions were delivered by peers, health care providers, and educators, largely in school‐based settings, and in many cases are part of sex‐education curricula. Evidence across geographies was mostly concentrated in Sub‐Saharan Africa (70%). Most measured outcomes focused on disease‐related knowledge dissemination and enhancing awareness of available prevention options/strategies. These included messaging around consistent condom use, limiting sexual partners, routine testing, and awareness. Very few studies were able to include psychographic, social, and contextual factors influencing AGYW health behaviors and decisions, especially those measuring the impact of social and gender norms, relationship dynamics, and household dynamics‐related outcomes. Outcomes related to engagement in the research were least studied. Conclusion This EGM highlights that evidence is heavily concentrated within the awareness‐intent spectrum of behavior change and gets lean for outcomes situated within the intent‐action and the action‐habit formation spectrum of the behavior change continuum. Most of the evidence was concentrated on increasing awareness, knowledge, and building risk perception around SRH domains, however, fewer studies focused on strengthening the agency and self‐efficacy of individuals. Similarly, evidence on extrinsic factors—such as strengthening social and community norms, relationships, and household dynamics—that determine individual thought and action such as negotiation and life skills were also found to be less populated. Few studies explore the effectiveness of these interventions across diverse AGYW identities, like pregnant women and new mothers, sex workers, and people living with HIV, leading to limited understanding of the use of these interventions across multiple user segments including key influencers such as young men, partners, families, religious leaders, and community elders was relatively low. There is a need for better quality evidence that accounts for the diversity of experiences within these populations to understand what interventions work, for whom, and toward what outcome. Further, the evidence for use of digital and mass‐media tools remains poorly populated. Given the increasing penetration of these tools and growing media literacy on one end, with widening gender‐based gaps on the other, it is imperative to gather more high‐quality evidence on their effectiveness. Timely evidence generation can help leverage these platforms appropriately and enable intervention designs that are responsive to changing communication ecologies of AGYW. SBCC can play a critical role in helping researchers meaningfully engage and collaborate with communities as equal stakeholders, however, this remains poorly evidenced and calls for investigation and investment. A full list of abbreviations and acronyms are available in Supporting Information: Appendix F.


| PLAIN LANGUAGE SUMMARY
High-quality evidence on the effectiveness of SBCC interventions for strengthening HIV prevention and research among adolescent girls and young women (AGYW) remains scattered and poorly documented, despite growing global recognition of the domain.

| Background
AGYW, aged 15-24 years, are disproportionately affected by HIV and other sexual and reproductive health (SRH). Converging social, cultural, and economic factors affect how adolescent girls and young women understand, negotiate and access information and biomedical treatment related to HIV. SBCC interventions form a pivotal part of the comprehensive HIV prevention response as they not only help address aspects of underlying socio-behavioral barriers that drive the epidemic, but also play a critical role in expanding knowledge of, and access to, quality health services, health equity and participation in research. They also assist in addressing gendered health disparities throughout the continuum of care (CDC, 2017). While the global buy-in for socio-behavioral interventions to support demand and uptake of HIV services is on the rise, evidence and impact of this in the context of AGYW needs to be systematically outlined and enumerated to enable informed decision-making by sponsors, researchers, policymakers and public health experts working on HIV.
factors that affect their capabilities to make decisions, enable them to translate intent into action and motivate them to make long-term behavioral shifts (Michie et al., 2014).
Most studies in this EGM focus on enhancing the knowledgerelated capabilities to create behavioral and health impacts situated within the awareness-intent spectrum of behavior change. However, evidence for interventions targeting outcomes situated within the intent-action and the action-habit formation spectrum are poorly populated. This highlights the need for more studies to focus on interventions that help achieve envisioned behavioral and health outcomes across the continuum that include various stagesawareness, knowledge, intent, trial, action, and habit formation (Prochaska & DiClemente, 1983).
Further, very few studies explore the effectiveness of these interventions across diverse AGYW identities-such as pregnant women and new mothers (PWNM), sex workers, and people living with HIV (PLHIV)-leading to a limited understanding of the use of these interventions across critical sub-populations and multiple user segments. This underscores the need for better quality evidence to understand what interventions work, for whom, and towards what outcome. It is, therefore, important to account for the diversity of experiences within AGYW populations, and better understand behavioral convergences and divergences to inform intervention design and evidence generation.
Realizing the value of communication channels in shaping behavior change discourse, this EGM actively looks at evidence across different communication strategies and platforms. However, we found that evidence towards the use of digital media tools such as social media and mobile-based services remains poorly populated.
Studies on the use of popular culture tools-including mass-media, theatre, and arts-based approaches-are also relatively low. Given the penetration of digital tools, increased access to mass media and growing media literacy on one end, with ever-widening gender-based gaps on the other, it is imperative to gather more high-quality evidence on the effectiveness of these tools. Timely evidence generation can help leverage this medium appropriately and enable intervention designs that are responsive to the changing communication ecologies of AGYW.

| How up to date is this EGM?
The authors searched for studies published up to April 2021.

| Positionality and Ethics Statement
The lead author, Devi Leena Bose, along with Anhad Hundal and Saif ul Hadi position ourselves as SBCC practitioners from LMIC working towards mainstreaming SBCC practices as an approach to help achieve sustainable development goals. We have been working with IAVI a nonprofit scientific research organization that develops vaccines and antibodies for HIV, tuberculosis, emerging infectious diseases (including , and neglected diseases. Through its various programs spread across India and Africa, IAVI aims to use SBCC strategies towards increasing knowledge, improving attitudes and enhancing practices of individuals and communities towards positive health seeking behavior and reduce barriers of vulnerable populations to contribute more to research and access prevention services. IAVI has co-created evidence-driven SBCC interventions for enhancing science literacy, research acceptance, research participation, using human-centered design and experiential learning. However, these interventions are not evaluated or influence the EGM in any manner. Other co-authors have no conflict of interest and have contributed to the EGM from a technical and methdolodological perspective. Converging social, cultural, and economic factors affect how AGYW understand, negotiate, and access information and biomedical treatment related to HIV. Persistent gender and age disparities and stigmas around female sexuality faced by this group in the impact of HIV are both exacerbated by, and reinforce, issues such as poverty, lack of access to education (including sexual and reproductive health education) and livelihood opportunities, limited financial autonomy, lack of access to sexual and reproductive healthcare (as well as other healthcare services), and the risk of violence, including intimate partner violence (IPV). A UNAIDS report found that nearly 1 in 3 women globally has experienced physical and/or sexual violence by an intimate partner, non-partner, or both, in their lifetimes (World Health Organization, 2021). Early marriage also poses special risks to young people, particularly women. years are newly infected with HIV every week, and 50 adolescent girls die from HIV-related diseases every day, including treatable diseases like cervical cancer (Stegling, 2019 has been an increase in the current use of family planning methods amongst married women (69% as per the NFHS-5, as compared to 54% reported in the NFHS-4), female sterilization remained the most reported method used, followed by condoms. This highlights the need to closely examine behavioral differences in seeking healthcare between married and unmarried women, along with disaggregation's based on age, regional and other socio-cultural aspects.

| Intervention
Methodologies centered on behavioral change have proven to be effective in the adoption and adherence of better health-seeking practices. While the global buy-in for socio-behavioral interventions to support demand and uptake of HIV services is on the rise, evidence mapping of the scope and impact of this in the context of AGYW needs to be systematically outlined and enumerated to help further adoption by researchers, policymakers and HIV program managers.
Social and Behavior Change Communication (SBCC) interventions form a pivotal part of the comprehensive HIV prevention response, as they not only help address aspects of underlying behavioral and social barriers that drive the epidemic, but also play a critical role in expanding knowledge of, and access to, quality health services, strengthen equity and participation and assist in addressing gendered health disparities throughout the continuum of care (CDC, 2017), thereby creating an enabling environment. However, there is also an understanding that, over the years, health communication has remained underutilized; not only is health communication often included in programs as an afterthought rather than integrated right in the beginning, the evidence towards creating this enabling environment, whereby uptake and support of prevention options and research is key, is often scattered (Sugg, 2016).

| Why is it important to develop this evidence and gap map (EGM)?
This EGM is important to map and consolidate existing evidence on SBCC strategies for HIV prevention and research among AGYW in LMICs. More simply put, this map helps understand what kind of SBCC interventions have been used with which population groups, towards what behavioral and health outcomes and, further, helps identify areas where more evidence and interventions are needed.
The knowledge generated through this EGM has the potential to support numerous stakeholders, including intervention designers, policymakers, program managers, community engagement practitioners, socio-behavioral researchers, donors, and the general public: • For socio-behavioral researchers, this exercise may provide an opportunity to explore the existing evidence base, be better informed about critical research gaps, and, therefore, design future research to address the same.
• For public health specialists and intervention designers, this EGM may provide a better understanding of the most effective strategies/approaches to engage diverse AGYW populations.
• For biomedical/public health researchers, this map may provide a preliminary understanding of an array of interventions and outcomes that can inform their methodologies to engage AGYW communities in research.
• For funders and decision-makers, this EGM can help to make informed decisions with regard to funding socio-behavioral BOSE ET AL.

| Existing EGMs and/or relevant systematic reviews
To the best of our knowledge, there are two existing EGMs (Portela et al., 2017;Rankin et al., 2016)

| Snapshot of the EGM
The primary dimensions of the map include intervention and the outcome. The online map also shows the secondary dimension T A B L E 1 List of existing EGMs and/or relevant systematic reviews (filters) such as country, region, population, study confidence, and so forth (Figure 1). • Rural informal-Community spaces like market areas, public meeting grounds, tea stalls, community fairgrounds, etc.
In addition to these, this EGM focuses on women living in a highrisk environment/s, for example, sex workers, etc. Further, the map also includes the influence networks of AGYW, primarily male partners, family elders, peers, key community members, and service providers.

Types of interventions
The SBCC interventions included in this EGM are divided into four key categoriesmass media-based interventions, community media-  (Table 2).
In case the interventions studied did not exactly match the above-mentioned categories, the team discussed and categorized them to their closest match based on the intervention definition and made a note of the same. Additionally, if a single study covered multiple interventions, the eligible interventions were coded and included.

Types of outcomes
The outcome categories in this EGM include behavioral and health-  Table 3 summarizes the outcomes in detail. Table 4 provides an overview of the inclusion and exclusion criteria that was used to code evidence during the development of this EGM.

| Search sources
The studies for this EGM were searched using a comprehensive search strategy (detailed in Supporting Information: Appendix A). A pilot search strategy was developed based on the selection of studies that met the inclusion criteria (

| Types of evidence
We included studies that assess the effects of interventions using experimental designs or quasi-experimental designs with non-random assignments that allow for causal inference (see criteria below).
Systematic reviews on the effect of interventions were also included, along with cross-sectional and panel studies 1 in addition to the designs that allow for causal reference.
As defined by Moher et al. (2015), "A systematic review attempts to collate all relevant evidence that fits pre-specified eligibility criteria to answer a specific research question. It uses explicit, systematic methods to minimize bias in the identification, selection, synthesis, and summary of studies. The key characteristics of a systematic review are (a) a clearly stated set of objectives with an explicit, reproducible methodology; (b) a systematic search that attempts to identify all studies that would meet the eligibility criteria; (c) an assessment of the validity of the findings of the included studies (e.g., assessment of risk of bias and confidence in cumulative estimates); and (d) systematic presentation, and synthesis, of the characteristics and findings of the included studies".
The key characteristics for a review to be included as a "systematic review" 1. A clearly stated set of objectives with pre-defined eligibility criteria for studies. 1 We have included RCTs, as well as other designs, with a comparison group mentioned in the report as impact evaluations. Further, we are aware that not all these designs included as impact evaluations, if assessed from a risk of bias tool, will indicate the same level of confidence as we can put in experimental designs as RCTs.

2.
A systematic search that attempts to identify studies that would meet the eligibility criteria.
3. A systematic presentation, and synthesis, of the characteristics and findings of the included studies.
We included impact evaluations that met the following criteria: Experimental and quasi-experimental studies: • Studies where participants are randomly assigned to treatment and comparison groups (experimental study designs).

T A B L E 2 Intervention categories
Intervention Intervention definition

Mass Media Interventions
Interventions that are characterized by expansive reach and are intended to reach a mass audience fall under mass media. These are large-scale and usually quite cost-intensive.

Print Media
Interventions that use print-based material, such as books, newspapers, journals, comics, novels, posters, and brochures to disseminate textual and visual information to diverse audiences on a large scale.

Electronic Media
Interventions that use audio-visual material, such as TV and radio to disseminate textual and visual information to diverse audiences on a large scale.

Community-Based Interventions
Interventions that are designed for/with the community where the key population of interest resides. In this, interventions are more localized and contextualized and aim at achieving a community buy-in.
Community Media Community media-driven interventions-such as community radio, video, newspapers, newsletters, and community screenings-encourage the participation of individuals, groups, or organizations through locally established and geographically specific media forms.

Folk Media
Interventions that use localized, traditional media in the form of music, drama, dance, and puppetry.
Theatre and arts-based approaches Interventions that use contextualized dramatic art forms to prompt community participation on specific issues.

Community Dialogues
Interventions that initiate open discussions and dialogues among participants and local groups through facilitated sessions that support self-reflection around issues about HIV/SRH.

Capacity Strengthening
Interventions targeted at strengthening the knowledge, skills, and capabilities of both providers and recipients of health services to adopt/deliver health interventions effectively.

Gamification and experiential learning
Interventions that support people-centric, hands-on learning, through pedagogies such as game components, participatory learning include the use of score, challenge, and achievement to motivate and engage participants (Kolb, 1984).

Interpersonal Communication
Interventions that involve one-to-one or small group interaction and exchange.

Counseling
Interventions that use one-on-one communication with a trusted communicator or community leader such as a counselor, teacher, or health provider.

Home Visits
Interventions where the homes of target populations and their influencers are visited by peers and community health workers to engage with them in a one-to-one and confidential manner.

Peer-led intervention
Interventions that use peer networks to ensure communication on a one-to-one basis, or in small and large groups

ICT and Digital Media-Based Interventions
Interventions are characterized by the use of technology and digital content creation which can be disseminated over the internet or mobile networks.

Social media
Interventions that use social media platforms such as Facebook, YouTube, TikTok, and Instagram to disseminate information and encourage users to interact with each other and engage in dialogue on a large scale.

Mobile-based services
Interventions that use mobile-based services such as SMS and IVRS to disseminate information and encourage users to interact with each other and engage in dialogue on a large scale.
Digital games and learning tools Interventions that use highly interactive and culturally relevant games and other tools through elements of roleplay and simulation to motivate users through sustained exposure.
Interactive app-based services Interventions that use interactive app-based services, at scale, to disseminate information about HIV prevention and treatment and provide other resources for support. BOSE ET AL.
| 9 of 52 • Studies where assignment to treatment and comparison groups is based on other known allocation rules, including a threshold on a continuous variable (regression discontinuity designs) or exogenous geographical variation in the treatment allocation (natural experiments).
• Studies with non-random assignment to treatment and comparison groups that include pre-and post-test measures of the outcome variables of interest to ensure equity between groups on the baseline measure, and that use appropriate methods to control for selection bias and confounding. Such methods include statistical matching (e.g., propensity score matching, or covariate matching), regression adjustment (e.g., difference-in-differences, fixed effects regression, single difference regression analysis, instrumental variables, and "Heckman" selection models).
• Studies with non-random assignment to treatment and comparison groups that include post-test measures of the outcome variables of interest only and use appropriate methods to control for selection bias and confounding, as detailed above. This includes pipeline and cohort studies.
Panel studies: Miranda (2014, 2017) argue that combining panel data with baseline observations and statistical matching is the most effective quasi-experimental method of reducing bias when evaluating conservation sector programs.
However, given the expected small size of the evidence base, we included studies with post-intervention outcome data only if they use some method to control for selection bias and confounding.
Cross sectional studies: Studies where paricipants are selected on the basis of the inclusion and exclusion criteria, after which the investigator follows the study and measures outcomes and exposures simultaneously (Setia, 2016) Excluded study designs: Before-after studies and observational studies without control for selection bias and confounding were excluded. Additionally, modeling-based studies, commentaries, and literature reviews were excluded.

| Stakeholder engagement
An advisory group comprising nationally and internationally recognized domain experts-including bioethicists, researchers, scientists, social scientists, experts in health education, gender mainstreaming, Good Participatory Practices (GPP), as well as advocacy and communication professionals-was convened.
Experts were consulted at four key stages during the development of this EGM: 1. At the inception to assist in defining the scope and review the draft conceptual framework.
2. During the review of search methods and strategies.
3. During the review of preliminary results where they also provided additional information on how to locate further relevant studies.
4. At the time of review of the draft report.
A detailed list of the advisors and experts has been included in were also explored through the EGM.
Based on the framework mentioned below, the substantive scope of the EGM was delineated along the following key categories: • Interventions consisting of SBCC intervention strategies. To keep the scope manageable, the EGM focused on the following topics of interest around HIV/AIDS and other STIs: • Testing and uptake of prevention options including condoms, PrEP (pre-exposure prophylaxis), PEP (post-exposure prophylaxis), and long-acting antiretroviral (ARV) drugs and other available or upcoming prevention options.
• Participation in biomedical research.
• Intimate partner violence, sexual violence, or gender-based violence affecting HIV and SRH-related health outcomes.

T A B L E 3 (Continued)
Behavioral outcomes Outcome definition 2. Quality of care and satisfaction with services Measures that help deliver desired health outcomes for AGYW and build user-friendly services. It is also related to the continuum of care in healthcare services HEALTH OUTCOMES Prevention 1. Limiting sexual partners Measures that promote risk reduction strategies convey that having multiple partners is risky.

Correct and consistent condom use
Measures that address the correct and consistent use of condoms every time individuals engage in sexual activity with their partners.

Routine testing and status awareness
Measures that relate to regular HIV testing, especially for those at high risk, for them to be made aware of their HIV status and subsequently get treatment.

Uptake of PrEP/other Biomedical prevention options
Measures that address the uptake of PrEP (pre-exposure prophylaxis), PEP (post-exposure prophylaxis), and long-acting antiretroviral (ARV) drugs and other available or upcoming prevention options.

Raised age of sexual debut
Measures that promote delaying sexual debut, especially for unmarried adolescent girls and women.
Research Engagement

Research Awareness and Benefit Perception
• Behavioral factors affecting access to sexual and reproductive health services, such as relationship goals, sexual negotiations, gaps in knowledge, self-efficacy, and risk perception.
• Stigma and discrimination related barriers.
• Collective action, community support, community-driven action,  Table 2 lists the intervention categories and sub-categories.

| Type of population
This study focuses on "Adolescent Girls and Young Women" as defined by UNAIDS (2019)

| Tools for assessing the risk of bias/study quality of included reviews
The purpose of the EGM was to identify all available impact evaluations and systematic reviews. The quality of the systematic reviews/metaanalyses was assessed with AMSTAR-2 (Shea et al., 2017). The risk of bias was not assessed for primary studies . To account for the differences in the quality of study designs and analysis methods, we appraised the risk of bias in all included systematic reviews by the risk of bias status. Studies with both negative and positive outcomes were considered for the above-mentioned designs.
6.2 | Analysis and presentation

| Presentation
The primary dimensions of the report include interventions and outcomes, as described earlier. Secondary dimensions or filters include region, country, year of publication, study setting, population sub-groups, and funding agency.

| Dependency
The unit of analysis is each paper. However, in cases where there are multiple versions of the same paper, the latest or most complete version is used for the analysis. Of the total 2502 records, 89 duplicates were further removed and a total of 2413 records were included for title and abstract screening.
Of these 2413 records, 904 reports were screened for full text.
A total of 431 reports were excluded at the full-text screening stage. Screening

| Evidence as per outcome category
As seen in Figure 6, prevention-related outcomes (n = 350) had the highest number of studies among all outcome categories, followed by studies on knowledge, attitude, and skills (n = 311). Studies with a focus on strengthening partner/relationship dynamics (n = 92) and addressing social and community norms (n = 83) were relatively lower. The least evidenced outcome categories included household dynamics (n = 29), healthcare services (n = 24), and research engagement (n = 5).

| Evidence as per outcome sub-categories
Given that SBCC interventions have been mostly targeted toward strengthening prevention-related outcomes, it is not surprising to see that correct and consistent condom use (n = 296) remains a densely studied sub-category, along with limiting sexual partners (n = 162), as seen in Figure 6. Further, given global efforts to amplify testing and treatment, we also see evidence for routine testing and status awareness (n = 92) being relatively better studied, while outcomes Additionally, distribution of evidence across study design (Figure 9) suggests that quasi-experimental studies were the most used methods across regions (n = 149), followed by randomized controlled trials (RCTs) (n = 142) and cross-sectional or panel study design (n = 138). However, trends vary across region-in Sub-Saharan Africa, the most used study design is RCTs, in South Asia, most studies use cross-sectional or panel study design, in East Asia and the Pacific a majority of studies use quasiexperimental study designs, and, in Latin America systematic reviews are the predominant study design.

Country-wise distribution of included studies by design
South Africa has the highest number of impact evaluations (n = 81) among all countries, as highlighted in Figure 10.

Distribution of evidence across settings
Evidence highlights that a majority of studies were conducted in informal (n = 251) and/or urban settings (n = 265), as seen in the graph below ( Figure 19). Evidence from rural (n = 148) and informal (n = 104) settings was relatively lower. It may be noted here, however, that in some of the studies, interventions were conducted in more than one setting. For example, an intervention conducted in a school in a rural area was coded under the categories rural and formal (e.g., Harrison et al., 2016). Some of the studies were conducted among patients receiving services at clinics in a city (e.g.

Distribution of evidence across intervention and population
Most interventions were targeted at adolescent girls (n = 533) followed by young women (n = 465). However, very few studies focused on population sub-categories like sex workers (n = 89) and PLHIV (n = 82).
Pregnant women and new mothers (n = 32) emerged as one of the least evidenced population sub-categories. Figure 20 highlights studies across different intervention categories and population sub-types.

Distribution of evidence by intervention and influencer
The distribution of included studies across intervention strategies and influencers ( Figure 21) suggests that peers (n = 208), educators (n = 184), and health care providers (n = 183) were the most studied influencers. A fewer number of studies included young men (n = 36), community elders (n = 32), partners (n = 19), religious leaders (n = 17), and family (n = 12).

Interpersonal communication was the most used intervention
technique across all sub-populations, apart from community leaders, religious leaders, and family, where more community-based interventions were utilized. ICT and digital media-based tools were most employed for healthcare providers (n = 8) and educators (n = 9).
F I G U R E 8 Distribution of included studies by region and broad study design. The number of studies does not equal the total number of studies as a single study may be coded as more than one study design (mostly a process evaluation with RCT/any other effectiveness design). high-risk category, and one of the key population groups. The same stands true for pregnant women and new mothers; however, one can understand that despite the at-risk category, this population subtype is traditionally not engaged in biomedical research.

| Quality assessment
Systematic reviews/meta-analyses were critically appraised with AMSTAR-2. A majority of the systematic reviews (89%) are rated Of all included systematic reviews, four were found to be of medium confidence (9%) and only one of high confidence (2%) (Figure 23).

Key findings
This EGM includes studies that employ the use of SBCC interventions targeted towards AGYW and their influencers for HIV prevention and engagement in research. We summarize some of the emerging findings and lessons in this section.

| Interventions
Evidence is unevenly distributed across different intervention types.
While there is a huge focus on interpersonal communication-based interventions, followed by community-based interventions, the use However, we see that the evidence for these kinds of interventions, both in physical (gamification and experiential learning) and digital spaces (digital games and learning tools), are largely missing.

| Outcomes
Prevention-related outcomes were most studied. However, outcomes related to more recent methods of prevention were less evidenced.
Among the outcome categories, prevention-related outcomes were most measured followed by knowledge, attitude, and skillsrelated outcomes. However, within these categories, data was unevenly distributed across sub-categories. Within preventionrelated outcomes, the most densely evidenced sub-categories include correct and consistent condom use, limiting sexual partners, and routine testing and status awareness. More recent methods of prevention, such as uptake of PrEP and other biomedical prevention options, were studied less.
Knowledge related outcomes are most studied with less focus on the continuum of behavior change.
Behavior change is a dynamic process. At an individual level, the behavior change continuum includes various stages-awareness, knowledge, intent, trial, action, and habit formation (Prochaska & DiClemente, 1983). In a real-world context Very few studies measured outcomes addressing aspects of opportunity-related barriers. These included outcomes related to social and community norms, household dynamics, and health care services, among others.
Research engagement outcomes remain poorly measured.
The role of SBCC interventions in supporting research engagement-related outcomes was poorly evidenced. Of the five studies that measured outcomes related to participation in biomedical research, four were from Sub-Saharan Africa and the remaining study was from India. Further, only one study measured outcomes related to research awareness and benefit perception.

| Others
We find that geographical coverage of evidence remains concen-

| Quality of the evidence
The confidence in the findings of systematic reviews was assessed using the AMSTAR-2 checklist. Most systematic reviews have been rated as being low confidence, followed by medium confidence. Only one systematic review was assessed to be of high confidence, indicating that the findings of these reviews should be used with caution. This was on account of some critical flaws, such as no assessment of risk of bias in primary studies, not using satisfactory techniques for assessing the risk of bias, or not providing the source of funding for the studies included in the review.

| Limitations of the EGM
This EGM is based on an as expansive a framework as possible, though limitations may remain in the scope and approach. We trust that other researchers will address the below limitations going forward, contributing to more robust evidence architecture in the future: 9 | AUTHORS CONCLUSIONS 9.1 | Implications for research, practice, and policy In this section, we draw linkages to various domains that the EGM touches on and seek to highlight nuances and specific evidence gaps that may not be obvious from the quick snapshots presented above.
We find that, although the evidence base for SBCC interventions is relatively large, it remains unevenly scattered across geographies and population sub-types and is mostly concentrated across a few interventions and outcomes. Given the high burden of HIV in the Sub-Saharan Africa region, evidence concentration is understandable.
However, other regions with a significant burden of HIV remain less studied, necessitating a more inclusive programming and evidence generation effort that is responsive to the regionally diverse needs of AGYW. Further, differences in quality of reporting make it critical to invest in gathering better quality evidence for the field to inform decision making and program design.
The current landscape of evidence highlights the need for a more nuanced and intersectional approach. It is critical to acknowledge the diversity within AGYW and understand that one size does not fit all.
We especially see evidence gaps for certain key sub-populations, such as pregnant women and new mothers, sex workers, and PLHIV.
Also, for the broader AGYW population, aspects of social positionality related to their age, education, marital status, family type (joint/ nuclear), of varying sexualities were not explored in the evidence base. Additionally, studies exploring the aspirations, desires, and life and relationship goals of AGYW were found to be largely missing.
All this calls for a behavioral and psychographic segmentation of the AGYW population along with better quality evidence to understand what interventions work, for whom, and towards what outcome. It is important that-going forward-program designers, implementers, and policymakers consider the diversity of this group and better understand behavioral convergences and divergences.
There is, therefore, a need to reframe the narrative in a manner that is not solely focused on disease knowledge-centered outcomes and which suits the needs of the AGYW.
This EGM highlights that evidence is heavily concentrated within the awareness-intent spectrum of behavior change and gets lean for outcomes situated within the intent-action and the action-habit formation spectrum of the behavior change continuum. In line with this, we find that studies mostly measure outcomes around the domains of knowledge, attitude, and skills, but get sparse around pathways enabling change, such as partner and relationship dynamics, household dynamics, and social and community norms, among others. While there is a lot of emphasis on building disease knowledge, improving risk perception, and increasing knowledge about a few prevention options, there is not enough emphasis on developing skills that can help translate intent into action and further habit formation.
We also witness that, within the category of influencers, peers, educators, and healthcare providers were most engaged. While the dominant engagement of peers is understandable given, they are key influencers within AGYW networks, the lack of engagement of other key influencers such as partners highlights a gap in intervention design. Hence, intervention strategies that will create an enabling environment for promoting safe and positive sexual health behaviors are necessary. To achieve this, an ecosystem-based approach that involves other influencers from their family/community, etc., and creates "safe spaces" for AGYW to openly share and discuss such intimate details of their life can be valuable.
The EGM reveals that most of the SBCC work done in the past is through the medium of interpersonal counseling or community-based engagements. Despite the penetration and influence of mass media and digital media-based tools, evidence for the utilization of the same for engaging AGYW remains limited. These media forms have the ability to shape and control "the scale and form of human association and action" (McLuhan & Lapham, 1964), yet remain an untapped opportunity. Given the blurring line between digital and physical spaces, it is important to understand changing media ecologies of AGYW networks and meet them where they are. It is important to be cognizant, however, that while the potential reach of these tools makes these valuable methods of engaging these diverse population, growing concerns around gendered access, issues of privacy, confidentiality, and cyber security warrant the need for more evidence to be generated to better understand and utilize these media forms in appropriate and ethical ways.
While gamified learning has emerged as one of the most promising interventional approaches to health-related behavior change, the EGM highlights that evidence for these kinds of interventions, both in physical and digital arenas, is under-explored.
Another key gap, and an urgent intervention area that the EGM

DECLARATIONS OF INTEREST
None.

PLANS FOR UPDATING EGM
The authors have no immediate plans to update this EGM.

DIFFERENCES BETWEEN PROTOCOL AND REVIEW
While finalizing this map, there have been some deviations from the protocol, informed by practical considerations, including: 1. Separation of "Community Dialogues" and "Capacity Strengthening" interventions as independent sub-categories within the larger "Community-Based Interventions" category.
2. Addition of "Delayed Sexual Debut" within prevention outcome measures.
3. Change from "peer-peer intervention" to "peer-led intervention." 4. Removal of "Intravenous Drug Users," "STI's" and "Mother-to-Child Transmission" as sub-populations of the key AGYW population group, and inclusion of "Pregnant Women and Young Mothers."

Internal sources
No sources of support were provided.

External sources
The EGM has been supported under the aegis of the ADVANCE